Visible Marks, Invisible Burdens: The Impact of Chronic Skin Disorder Stigmatization In Children

Original Article: Stigmatization and Mental Health Impact of Chronic Pediatric Skin Disorders

What are the key takeaways of this article?

Chronic skin conditions significantly affect individuals' physical, mental, and social well-being, especially when diagnosed in childhood. Despite the profound impact that these disorders can have on psychosocial development, they are often considered less serious than other medical conditions by the public, insurers, and the pharmaceutical industry. This misconception fails to recognize the risk of bullying, alienation, and stigma faced by children and adolescents with chronic skin disorders. Stigmatization can alter social attitudes and skills development, leading to reduced self-worth. It can be perceived (through fear of discrimination) or experienced directly. Although stigma has been addressed in many chronic medical conditions, it has received limited attention in the context of children's skin disorders due to a lack of adequate validated tools for study.

This study aims to investigate the correlation between the level of stigmatization associated with disease visibility, severity, mental health, and quality of life (QOL) in children and adolescents with chronic skin disorders. This cross-sectional, single-visit study was conducted with parent/child dyads recruited from 32 sites across the US and Canada, involving 1,671 children aged 8-17 years. Participants had chronic skin diseases (present for at least six months) with at least moderate severity, or visibly apparent when wearing clothes, as assessed by a physician.

The primary outcome was to measure childhood stigma in relation to disease visibility. Secondary outcomes compared child-assessed stigma scores with disease severity, QOL, anxiety, depression, peer relationships, and parental responses. Disease severity was measured by physician, patient, and parent global assessments, categorizing it as mild, moderate, or severe. The Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) stigma-skin tool was used to assess stigma, while QOL was measured using the Skindex-Teen tool.

The most common chronic skin disorders included in the study were acne, atopic dermatitis, alopecia areata, and vitiligo. Interestingly, stigma scores significantly differed by disease visibility and severity. 27% of children had minimal or no stigma, while 43.8% experienced at least moderate stigma. Unsurprisingly, stigma scores strongly correlated with reduced QOL, depression, anxiety, and poor peer relationships. Notably, 29.4% of parents were aware of their child being bullied, which was strongly associated with stigma. Additionally, girls reported stigma more frequently than boys. Lastly, children with hyperhidrosis and hidradenitis suppurativa were most likely to experience increased depression and anxiety.

Stigma is a greater issue for children with higher disease visibility and severity. However, the authors highlight that even children with less visible disorders can experience stigma, emphasizing the need for more comprehensive care. Physicians should be aware of stigmatization's potential impact on children with chronic skin conditions. Beyond treating the underlying skin disease, interventions such as discussions with teachers, educating classmates, managing bullying, and psychological support can help mitigate stigma's impact.

In summary, this study centralizes stigma as one of the major impacts of chronic skin disease on QOL and mental health in the pediatric population. Though some skin diseases may not be obvious, some children may still suffer from the impacts of stigma which can hinder their overall development. Thus, improving treatments and addressing these conditions' medical and psychological aspects are crucial to reducing stigma and disease severity, ultimately enhancing these children's lives.

Publication Date: June 3rd, 2024

Reference: Paller AS, Rangel SM, Chamlin SL, et al. Stigmatization and Mental Health Impact of Chronic Pediatric Skin Disorders. JAMA Dermatol. Published online April 24, 2024. doi:10.1001/jamadermatol.2024.0594

Summary By: Sascha Azoulay